Ch.16 Intracranial Regulation-Neurologic Disorder SATA questions

The nurse is caring for a child who was injured in a bike accident. The nurse determines that a child is experiencing late signs of increased intracranial pressure based on which assessment findings? SATA.

1) Bradycardia 2) Fixed dilated pupils 3) Irregular respirations

The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention?

1) Increased head circumference 2) Vomiting 3) Parent states that my infant doesn't act right

When assessing a neonate for seizures, what would the nurse expect to find? SATA.

1) Tachycardia 2) Elevated blood pressure 3) Jitteriness 4) Ocular deviation

The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? SATA.

1) Time the seizure started 2) Factors present before the seizure started 3) Eye position and movement 4) Incontinence of urine or stool

The meningococcal vaccine should be offered to high-risk populations. If never vaccinated, who has an increased risk of becoming infected with meningococcal meningitis? SATA.

1) 18 YO student who is preparing for college in the fall and has signed up to live in a dormitory with two other suite mates 2) 12 YO child with asthma 3) 5 YO who routinely travels in the summer with her parents on mission trips to Haiti 4) 9 YO child who was diagnosed with diabetes when he was 7 YO.

The community health nurse is preparing a presentation on safety measures to prevent injuries in children. Which example of proper safety guidelines should the nurse include? SATA.

1) A child wearing a helmet while ice skating 2) An infant in a car seat 3) A child wearing a helmet, knee pads, and elbow pads while riding a skateboard.

A child is hospitalized and diagnosed with bacterial meningitis. What can the nurse anticipate will be included in the plan of care and treatment? SATA.

1) Acetaminophen 2) Abx therapy 3) Tepid baths as needed

The nurse is preparing a care plan for a toddler diagnosed with cerebral palsy (CP). Which intervention would be appropriate for the nursing diagnosis of Risk for disuse syndrome related to spasticity of muscle groups? SATA.

1) Administer carbidopa/levodopa as prescribed. 2) Administer benzodiazepines as prescribed 3) Teach parents exercises and games to help prevent contractures.

The parents of a 10-month-old child bring the infant to the emergency department after finding the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone." Which assessments are priority for the nurse to complete? SATA

1) Airway 2) Respiratory status 3) Circulation

The nurse is talking with a teen and her parents about triggers for her frequent headaches. Which statements indicate an understanding?

1) I may experience headaches during certain periods in my menstrual cycle. 2) Giving up cola may be beneficial to helping me avoid headaches. 3) Chocolate may trigger my headaches.

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? SATA.

1) Oxygen gauge and tubing 2) Suction at bedside 3) Padding for side rails

An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child? SATA.

1) Request order for an antiemetic. 2) Assess intake and output every shift. 3) Assess child's skin for the development of distinctive rash every 4 hours. 4) Request order for an anticonvulsant.

The community health nurse has just completed a presentation to a group of parents regarding drowning prevention. Which statements by the parents indicate understanding of the teaching?

1) Since we have a 16 YO, I am really concerned about supervision when our child is swimming in the ocean. 2) We always make sure our babysitter keeps her CPR training up to date. 3) It is scary to think we have a pool and drowning is the second leading cause of accidental death in children. 4) We make sure to keep our bathroom door closed when our 10 month old is walking around the house since the door handle is too high to reach

The young boy was involved in a motor vehicle accident and was admitted to the PICU with changes in LOC and a high-pitched cry. Which are late signs of IICP? SATA.

1) The child's toes are pointed downward, his head and neck are arched backward, and his arms and legs are extended. 2) The child's heart rate is 56 bpm. 3) The child's pupils are fixed and dilated.

The nurse is providing discharge teaching to the parents of a child recently diagnosed with a seizure disorder. The nurse determines learning has occurred with which statement(s) by the parents? SATA.

1) We will be sure to keep the area safe and turn our child on the side during seizure activity. 2) We should time the seizure and write down what happens during the seizure.

A 13-year-old adolescent is being released from the hospital following examination for a concussion. The parent has agreed to monitor the adolescent at home for the next 24 hours. Which instruction(s) should the nurse provide? SATA

1) Assess the adolescent's LOC every 1 to 2 hours while awake. 2) Ask the adolescent to name a familiar object. 3) Ask the adolescent to state where he or she lives.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's LOC. What would the nurse assess? SATA.

1) Eye opening 2) Verbal response 3) Motor response

The nurse is caring for a child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What action(s) by the nurse should be performed now? SATA.

1) Check tubing clamps to ensure they are open. 2) Ensure the tubing is not kinked.

The nurse is completing a nursing history on a female client who has just found out she is 6 weeks' pregnant. She reports that over the last 2 months she has been drinking excessive amounts of alcohol every weekend and smokes a half-pack of cigarettes per day. What is the nurse concerned with given this information?

1) Brain development in the fetus 2) Spinal cord development in the fetus

A nurse is reviewing the results of a lumbar puncture of a child. The nurse identifies which results as being abnormal? SATA

1) Cloudy in color. 2) Granulocytes are present

A nurse is providing care to a child with status epilepticus. Which medications would the nurse identify as appropriate for administration? SATA.

1) Diazepam 2) Lorazepam 3) Fosphenytoin

An infant is brought to the emergency department after falling off the parents' bed and hitting the head. The infant is diagnosed with a concussion and is safe to return home. Which instruction(s) does the nurse provide the parents for home care of this infant? SATA.

1) Have someone in the home with your infant for the next 24 hours. 2) Return to the emergency department if your infant vomits more than 2 times. 3) Return to the emergency department if you notice your infant's pupils are different sizes.

Upon assessment of an infant the nurse suspects the child has positional plagiocephaly. What questions should the nurse ask the parents to help confirm if this is correct?

1) How much tummy time do you plan each day for your infant? 2) Besides transporting your infant in the car, how much time do you place your infant in the car seat every day? 3) Do you follow the recommended guidelines of placing your infant on the back to sleep rather than the abdomen?

The nurse is caring for a 3-year-old child who experienced a febrile seizure for the first time. What statements by the parents of the child should the nurse address further?

1) I am afraid that our 10 YO will start having febrile seizures 2) It is so scary to think that our child will likely develop epilepsy now.

The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? SATA.

1) Initiate droplet precautions. 2) Identify close contacts of the child who will require post-exposure prophylactic medication. 3) Administer Abx as ordered. 4) Initiate seizure precautions

A 12-year-old child has suffered a concussion after being in an automobile accident. What will be included in the plan of care/treatment? SATA.

1) Observation of LOC 2) Rest

The nurse is preparing an in-service for the staff about abusive head trauma (shaken baby syndrome). When planning to review risk factors, what should be included? SATA.

1) Teen parents 2) Infant with colic 3) Premature infants 4) Financial concerns in the family.

When caring for a child who has a history of seizures, which nursing intervention would be appropriate? SATA.

1) The nurse pads the crib or side rails before a seizure. 2) The nurse positions the child on the side during a seizure. 3) The nurse stays with the child and calls for help when a seizure begins. 4) The nurse has oxygen available to use during a seizure. 5) The nurse teaches the caregivers regarding seizure precautions.

The nurse has performed discharge teaching for parents of a child diagnosed with epilepsy. The child has been prescribed Zonegran (zonisamide). Which comments by the parents indicate the need for further discharge teaching regarding this medication? SATA

1) This medication can make our child very sedated so we need to monitor for this side effect. 2) We need to watch our child's gums for swelling since this commonly happens with this medicine. 3) We may need to add B-complex vitamin supplementation to our child's medications because this can help manage side effects.

The nurse is reinforcing teaching with caregivers of a child being discharged from the urgent care setting following a mild head injury that occurred in a roller skating accident. What should the caregivers be instructed to do? SATA.

1) Wake the child every 1 to 2 hours to check LOC. 2) Observe and report any vomiting that occurs within 6 hours. 3) Observe for a report to provider any double or blurred vision.

A child is brought to the emergency center after sustaining a seizure at home. When taking the child's history, which question(s) would the nurse ask the parents? SATA.

1) What time did the seizure start? 2) Can you describe to me the movements your child experienced? 3) How long did the seizure last? 4) Did your child lose bladder or bowel control? 5) Did your child stop breathing during the seizure?